CARRIAGE RELATED HEAD INJURIES: A Neurosurgeon’s Advice

Richard A. Close MD FACS

Head injuries are common among participants in collision sports.  Although carriage driving is not a collision sport per se, the elements of speed, machinery and the involvement of animals, that no matter how well trained can produce dangerous circumstances, all make for including carriage driving when we consider traditional collision sports such as football, rugby, lacrosse, etc.

By far the commonest head injury is cerebral concussion. This is defined as a brief alteration of consciousness after a blow to the head, or a severe shaking of the head. it is followed shortly thereafter by complete neurological recovery. Alteration of consciousness can range from total unconsciousness to what people often describe as seeing stars.  The problem  is that the diagnosis of concussion is retrospective. So at the time of the injury, even if the victim awakens and  appears to be normal, there may be something more serious . This factor coupled with the tendency of athletes to under-report symptoms so as  not to be removed from the field of competition makes  proper care of these victims quite challenging.

When approaching the head injured individual first remember that a person suffering a head injury has roughly a one in five chance of also having a spine injury as well. So treat the victim as though the spine has been injured until you can get a reliable response that there is absolutely no spine pain at all and there is no tenderness of the spine. If the victim remains unconscious, then he/she must be treated as though there is a spine injury and proper spine precautions taken. Assuming that there is no spine symptomatology whatsoever and the athlete is now awake, then remove him/her to a safe place and out of the competition. Although it is unlikely that someone who awakens and appears totally normal and symptom-free following a concussion event is suffering from an anatomical injury to the brain such as a blood clot, this must be considered, and so the next step is have the victim evaluated by a physician. This should be done immediately; emergently if the victim is unconscious. It should not wait until the end of the show or when it might be more convenient.  Now means now!

I am reminded of the tragic story of Mark Donohue, a champion race driver, who crashed his F1 racer while competing in rural Germany in 1975.He was said to have walked away from the crash but while sitting in the pits lapsed into coma, was evacuated to a center and died from a brain hemorrhage. Certainly his chances would have been better had he been immediately evacuated despite the fact that he was awake and walking around.

Truth be told, my experience of over 50 years is no different than that of most other neurosurgeons in that roughly only 10% of head injury patients ever require neurosurgical intervention(surgery) The challenge is identifying those who fall into that small population and get them treated before coma occurs. Time is both an enemy and a friend.  This is certainly true in carriage driving where competitions are often held in remote areas. It is best to err on the side of caution. There is no need to apologize for insisting that someone who has suffered a concussion event be taken to an emergency room and properly evaluated. A normal evaluation does not mean that the victim did not need to be evaluated! The same holds true for a CAT scan. Computerized axial tomography (CAT scan) is arguably the greatest invention of the 20th century. Countless lives have been saved because of the CAT scan. It is highly accurate in diagnosing traumatic injuries such as brain hemorrhage. The time to do an intervention that is safe and life- saving is when you first think of it. There are many formulas and guidelines, as to when a CAT scan should be done. My feeling is that if the caregiver thinks of it, he should do it and be done with it.

After care of a concussion is most important. This involves resting and not stressing the brain. It is not necessary to wake the victim up every hour. Rather, periodically checking on the victim to make sure he is breathing normally  is sufficient. Avoiding mental tasks, stress, and use of TV or computer screens is recommended. The athlete should not return to competition until he/she is symptom-free on no medications at rest and tolerates resumption of the sport. A symptom complex known as post-concussive syndrome includes headache, irritability, difficulty learning, depression, sleep disturbance,  cognitive complaints etc will more often occur in an individual who does not allow  proper post recovery care and pushes to resume full activity while still symptomatic. Recovery, following a concussion can take days to weeks.  If questions arise about resumption or increase of symptoms during the recovery phase, the athlete should be reevaluated for complications of the head injury, which may be something more than a simple concussion.

A normal diet and normal hydration are important. All alcohol must be strictly avoided. Effort should be made to discontinue nicotine. Tylenol is the drug of choice for post-concussive headaches. Again, should the headaches increase, reevaluation should be done.

Repeated concussions are to be avoided. Current teaching holds that three strikes and you’re out;,that is, an  athlete who has sustained three concussions while playing a collision sport is best advised to give up the sport. This is a hard lesson learned over the years by former football players who played prior to the establishment of strict concussion protocols. It was also illustrated for all  the world to see by the unfortunate outcome suffered by Muhammad Ali.

Besides the dangers inherent in the sport of carriage driving itself, there are other risk factors that need to be considered. These include age(50 or older) and use of anticoagulants.  Older individuals are prone to develop late complications of minor head injuries, such as concussion, and should be carefully watched. For example, a stroke that occurs a month or two after a bump on the head at a competition may well be a blood clot, which can be removed and corrected and allow complete recovery.  Use of blood thinners will make the athlete more prone to hemorrhage, and therefore should be considered when confronted with a seemingly minor head injury. Alcohol should be avoided for at least 12 hours before competing.

Another hard lesson that has been learned by the National Football League is that athletes are highly competitive individuals and will not allow themselves to be removed from a game after a concussion. For this reason, it has been mandated that an expert. be placed in the press box during every NFL game and be in direct communication with the referee who will then remove a player who is acting suspiciously after a blow to the head. Such was done this past season when Jalen Hurts of the Philadelphia Eagles sustained a blow to the head during a game.. He was removed from the game by the spotter and sat out another game after he was diagnosed as having suffered a concussion. He completed the concussion protocol and returned to play and ended up as the most valuable player in the Super Bowl. The point here is that those in charge of carriage competitions must realize that victims of head injury do not want to admit to being injured and certainly do not want to leave the competition, leave their horse, etc. The solution and the proper action is not negotiation but insist that EMTs be  called, the victim  excused from the competition and taken to the nearest emergency room for proper evaluation and treatment. The consequences of not doing this, while not often the case are extraordinarily severe when they occur!

Finally, the helmet. Regulation helmets, save lives!  Ideally, we should be wearing a helmet whenever we are around horses-just like we teach the pony clubbers. Certainly, we should be wearing a helmet whenever we are in a carriage. Much as I would like to be wearing a derby or a sporty fedora when I am in the dressage ring, I know better. And you should too! It’s like this: if you don’t think that your brain is worth $75(the cost of a helmet) to protect it, you’re probably right!

Have fun and drive safe!